HX641 38224 
RC862  .F76  Intussusception  in  c 


. 


RECAP 

INTUSSUSCEPTION  IN  CHILDREN. 


W.   E.   FOKEST,   M.D., 

New  York. 


Reprinted  from  The  American  Journal  of  Obstetrics  and  Diseases 
of  Women  and  Children;  Vol.  XIX.,  July,  1886. 


COLUMBIA  UNIVERSITY 

DEPARTMENT  OF  PHYSIOLOGY 

College  of  Physicians  and  Surgeons 
4s7  west  fifty  ninth  street 

NEW  YORK 

NEW    YORK: 
WILLIAM   WOOD   &   COMPANY,    56    &  58  LAFAYETTE   PLACE. 

1886. 


££I6Jl 


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INTUSSUSCEPTION  IN  CHILDREN 


BY 


W.    E.   FOEEST,  M.D., 

New  York. 


Reprinted  from  the  American  Journal  of  Obstetrics  and  Diseases  of 
Women  and  Children,  Vol.  XIX.,  July,  1886. 


NEW  YOEK  : 
WILLIAM   WOOD   &   COMPANY,    56   &  58    LAFAYETTE    PLACE. 

1886. 


"KG  £6.2. 

Fig 


INTUSSUSCEPTION  IN  CHILDREN. 


Case  I. — In  July,  1880,  a  child  eight  months  old  was  brought 
to  me  for  treatment  for  diarrhea.  It  was  much  reduced  in  flesh  and 
strength.  I  saw  the  child  one  afternoon,  and  recommended  the 
mother  to  take  it  to  the  sea-shore  the  next  morning,  and  remain 
on  the  beach  during  the  day.  The  same  evening  the  mother 
noticed  a  lump  in  the  right  hypochondriac  region  that  moved  at 
times  towards  the  left  side. 

The  child  passed  a  restless  night,  occasionally  screaming,  and 
the  diarrheal  discharges  gave  place  to  bloody  passages,  accom- 
panied with  tenesmus.  In  the  morning,  without  seeing  me  or 
notifying  me  of  the  new  symptoms,  the  child  was  taken  to  the 
sea-shore.  The  mother  had  already  noticed  that,  after  violent 
expulsive  efforts,  what  she  called  the  child's  "body  "  came  down. 
During  the  day  the  child  had  occasional  attacks  of  screaming  and 
straining,  accompanied  by  the  same  bloody  discharges.  In  the 
evening  I  was  called  in,  this  being  about  twenty-four  hours  after 
symptoms  of  intussusception  had  become  prominent.  Found  the 
little  patient  with  a  rapid  pulse,  eyes  sunken,  cold,  and  vomiting. 
No  tympanites. 

An  oblong  tumor  could  be  felt  in  the  left  iliac  region.  When 
the  abdomen  was  manipulated,  the  child  made  expulsive  efforts 
which  forced  out  about  two  inches  of  the  invaginated  intestine. 

The  diagnosis  was  readily  made.  I  at  once  attempted  to 
remedy  the  difficulty.  The  patient  was  held  in  a  reclining  posi- 
tion, with  head  and  shoulders  lower  than  the  hips,  and  attempts 
were  made  to  force  back  the  invaginated  intestine  by  means  of  in- 
jections of  warm  water  through  a  Davidson's  syringe.  The 
sphincter  ani  was  so  markedly  relaxed  that  two  fingers  passed 
through  without  difficulty,  and,  owing  to  this  relaxation,  it  was 
impossible  to  confine  the  injections   in  the  bowel.     As  soon  as 


4:  Forest:  Intussusception  in  Children. 

three  or  four  ounces  had  been  thrown  in,  an  expulsive  effort 
would  drive  out  every  particle  of  the  liquid  at  the  side  of  the 
nozzle  of  the  syringe,  and  force  the  intestinal  tumor  down  upon 
the  syringe  nozzle  with  considerable  force. 

Finding  my  efforts  unavailing,  I  called  in  a  neighboring  physi- 
cian  to  assist  me.     The  child  was  suspended  for  a  few  minutes 
with  its   head   downwards.      The   assisting   physician   held   the 
nozzle   of  the   syringe  in   the   anus   and   supported    the  relaxed 
sphincter  with  his  hands,  while  I  attempted  to  inject  warm  sweet 
oil.     In  spite  of  the  position  of  the  child  and  every  endeavor  on 
the  part  of  my  assistant  to  constrict  the  anus  and  retain  the  in- 
jection, it  was  expelled  repeatedly.     The  expulsive  force  of  the 
abdomen  in  this  weak  child  was  almost  incredible.     After  inter- 
mittent attempts  for  more  than  two  hours, we  were  compelled  to  give 
up  these  efforts  and  to  propose  the  operation  of  abdominal  section. 
To  this  the  parents  would  by  no  means  consent,  and  so,  it  being 
nearly  midnight,  we  left  the   case  for  the  night.     On   my  way 
home  I  thought  of  a  measure  that  might  perhaps  be  of  service. 
I  stepped  into  a  drug  store,  and  procured  an  old-fashioned  glass 
vaginal  syringe,  one  inch  in  diameter  and  six  inches  in  length, 
with  a  rounded  end,  perforated  by  a  number  of  small  openings. 
From  the  syringe  I  removed  the  piston  and  fitted  a  cork  in  the 
open  end,  with  a  hole  in  the  cork  just  large  enough  to  receive  the 
nozzle   of    a  Davidson's  syringe.      I  removed  the    rubber  tube 
with  the  nozzle  in  front  of  the  bulb  of  the  syringe  and  passed 
the  nozzle  through  the  hole  in  the  cork.    A  little  melted  sealing- 
wax   dropped  on  the   cork  held  the  nozzle  in  place  firmly,  and 
made  the  joints  air-tight.     The  other  end   of  the  rubber  tube 
was  then  slipped  over  the  nozzle  of   a  siphon  of  Vichy  water  and 
fastened.     I  then  made  a  shoulder  on  the  glass  vaginal  syringe 
about  an  inch  from  the  perforated  end,  by  winding  a  roller  band- 
age tightly  around  it.     This  bandage  was  wound  so  as  to  make  a 
firm  shoulder  an  inch  in  thickness  all  around  the  tube,  and  made 
slightly  cone  shape.    My  apparatus  consisted,  then,  of  a  siphon  of 
Vichy  water   warmed  to  the   temperature  of   the  body,  a  small 
rubber  tube  about  two  feet  in  length  connecting  the  siphon  with 
a  glass  tube  one  inch  in  diameter  and  six  inches  in  length.     The 
end  of  the  glass  tube  that  entered  the  rectum  was  rounded  and 
perforated  with  a  number  of  openings.     One  inch  from  this  ex- 
tremity was  a  shoulder  formed  by  a  roller  bandage. 

The  apparatus  being  complete,  1  proceeded  to  put  it  to  the  test. 
The  glass  syringe  was  inserted  in  the  anus  until  the  shoulder  on 
it  pressed  firmly  up  against  the  parts  about  the  sphincter  ani  and 
thus  supported  them.  Then  I  cautiously  depressed  the  cock  on 
the  siphon.  Not  till  this  moment  did  the  completeness,  and  (if 
I  may  be  allowed  the  expression)  the  beauty  of  the  apparatus 
appear. 

Whereas  with  the  ordinary  method  of  injection,  two  physicians 
had  found  themselves  totally  unable   to  force  any  considerable 


Foeest  :  Intussusception  in  Children.  5 

amount;  of  liquid  into  the  intestine,  owing  to  the  relaxation  of  the 
sphincter  and  the  powerful  expulsive  efforts  of  the  child,  now  hy 
the  pressure  of  one  finger  upon  the  cock  of  the  siphon  I  was  en- 
abled to  give  an  injection  without  the  escape  of  a  drop  of  the  in- 
jected fluid.  With  the  utmost  ease  I  could  bring  to  bear  upon 
the  invaginated  intestine  an  elastic  pressure  of  gas  and  water  that 
might  be  increased  at  will  up  to  almost  any  amount.  Very  slowly 
then,  barely  a  drachm  at  a  time,  I  allowed  the  gas  and  liquid  to 
escape  from  the  siphon  into  the  glass  tube  and  so  into  the  colon. 
When  an  expulsive  effort  came  on  I  at  once  stopped  the  injection, 
when  part  of  the  fluid  would  be  driven  back  into  the  glass  tube 


and  there  meet  with  an  elastic  cushion  of  carbonic  acid  gas,  that 
while  yielding  somewhat  to  the  expulsive  force  of  the  abdomen, 
still  kept  up  a  continuous  pressure  on  the  tumor  and  gradually 
forced  it  upwards.  In  twenty  minutes  I  found  by  abdominal 
palpation  that  the  tumor  had  risen  somewhat  in  the  left  iliac 
fossa,  and  that  the  expulsive  efforts  of  the  child  were  less  violent. 
Thirty  minutes  later,  no  marked  tumor  could  be  felt  in  this 
region,  but  there  was  still  an  obscure  swelling  in  the  right  hypo- 
chondriac region. 

I  then  had  the  child  held  in  a  semi-reclining  posture,  with  the 
shoulders  higher  than  the  nates,  so  that  gas  might  rise  upwards, 
and  inverted  the  siphon  so  that  carbonic  acid  gas  alone  could  es- 
cape from  the  siphon  into  the  rectum.  As  the  gas  rose  up 
through  the  portion  of  the  colon  below  the  tumor  and  pressed 
against  it,  there  was  a  faint  rumbling  sound  and  immediately  all 
signs  of  an  intussusception  disappeared.  The  child  was  then 
given  an  anodyne,  and  soon  fell  into  a  quiet  slumber.  Two  hours 
later,  a  natural  feculent  discharge  came  from  the  bowels. 

Case  II. — An  infant,  five  months  old,  in  ordinary  good  health 
except  that  it  was  teething  and  had  a  slight  diarrhea,  was  taken 
in   the   evening  with   sudden   attacks  of   crying  and  screaming. 


6  Fokest  :  Intussusception  in  Children. 

These  attacks  were  paroxysmal  in  character.  The  child  vomited 
occasionally.  About  2  a.m.  to  these  symptoms  were  added  dis- 
charges of  blood  accompanied  by  marked  tenesmus.  The  parents 
then  summoned  me.  I  found  the  symptoms  already  mentioned. 
The  child  was  pale,  but  not  yet  collapsed.  Suspecting  what  the 
trouble  might  be,  I  at  once  examined  the  abdomen  and  found  a 
tumor  in  the  left  hypochondriac  region.  On  passing  the  finger 
through  the  dilated  sphincter,  and  as  far  as  possible  into  the  rec- 
tum, it  came  in  contact  with  the  end  of  the  invaginated  portion 
of  the  intestine. 

The  diagnosis  was  plain.  Without  delay  I  procured  my  simple 
apparatus  and  the  siphon  of  Vichy,  and  commenced  giving  the 
injection.  The  tumor  was  gradually  forced  upwards.  The  ex- 
pulsive efforts  of  the  child  became  less  and  less  violent  as  the 
tumor  rose,  until  at  length,  before  the  invagination  was  reduced, 
the  child  fell  into  a  doze.  It  had  had  neither  opium  nor  an 
anesthetic.  In  one-half  hour  there  was  no  sign  of  a  tumor  pres- 
ent. There  was  a  faint  rumbling  sound  at  the  close,  much  as  is 
heard  when  a  hernia  is  reduced.  I  gave  the  child  an  opiate. 
The  next  day  it  appeared  well  and  made  a  good  recovery. 

Case  III. — In  April,  1885,  I  was  called  to  see  a  girl  of  5  years, 
who  had  had  intermittent  pain  in  the  abdomen  for  two  days. 
She  then  began  to  have  well-marked  tenesmus  with  the  passing 
of  blood. 

On  examining  the  abdomen,  I  discovered  a  tumor  in  the  right 
hypochondriac  region.  This  tumor  was  movable  slightly  and 
during  a  pain  became  somewhat  harder,  "  rose  up  "  under  the 
hand,  and  moved  slightly  upwards.  The  patient,  however,  was 
very  comfortable  between  the  paroxysms  of  pain,  there  was  no 
collapse,  no  vomiting,  and  no  dangerous  symptoms  of  any  kind, 
such  as  were  present  from  the  first  in  cases  I.  and  II.  Tenesmus 
was  well  marked,  however. 

In  making  the  differential  diagnosis  in  this  case  (and  I  must 
confess  I  was  a  little  in  doubt  at  first,  owing  to  the  absence  of 
acute  symptoms),  I  had  to  consider  whether  the  tumor  might  not 
be  impacted  feces.  Against  this  theory  was  the  "feel"  of  the 
tumor  itself  :  it  did  not  have  the  doughy  feel  that  impacted  feces 
are  said  to  have  in  most  cases.  The  tumor,  too,  was  somewhat 
erectile,  which  is  said  to  be  characteristic  of  a  tumor  due  to  in- 
tussusception. Then  again,  in  impacted  feces  there  is  rarely 
marked  tenesmus  and  passing  of  blood  unless  the  impaction  is  in 
the  sigmoid  flexure,  which  was  not  the  case  here,  the  tumor  being 
in  the  region  of  the  ascending  colon. 

From  these  considerations  I  decided  that  it  was  a  case  of  sub- 
acute intussusception,  probably  ileo-cecal.  Owing  to  the  absence 
of  acute  symptoms,  I  decided  to  treat  the  case  tentatively,  and 
immediately  began  to  carefully  administer  opium,  and  then 
waited  for  other  indications  before  commencing  active  treatment. 
After  a  few  hours  the  pain   and  tenesmus  gradually  subsided. 


Forest  :  Intussusception  in  Children.  7 

Fomentations  of  the  abdomen  were  then  added  to  the  other  treat- 
ment.    The  patient  passed  a  comfortable  day  and  night. 

The  next  day  (twenty-four  hours  after  beginning  treatment), 
the  tumor  was  present,  but  slightly  smaller.  A  little  blood  still 
passed,  but  tenesmus  was  absent.  I  continued  the  treatment 
and  employed  massage  to  some  extent. 

The  third  day  the  tumor  could  not  be  felt.  In  the  evening 
the  child  had  a  passage  of  natural  consistency  and  made  a  speedy 
recovery.  There  was  no  evidence  in  the  passage  of  hardened, 
feces. 

Intussusception  or  invagination  of  the  bowel  in  children  is  an 
affection  of  great  interest  to  the  physician,  not  so  much  because 
of  its  frequency,  though  it  occurs  oftener  than  is  usually  sup- 
posed, but  on  account  of  its  dangerous  tendency  unless  promptly 
and  carefully  treated. 

The  varieties  of  invagination,  classified  according  to  situation, 
are  four. 

1st.  Invagination  confined  to  the  small  intestine. 

2d.  Ileo-colic :  the  small  intestine  passing  through  the  ileo- 
cecal valve  into  the  colon. 

These  two  varieties  are  extremely  rare  in  children  under  ten 
years  of  age,  and  it  is  doubted  by  some  writers  whether  the 
first  ever  occurs  in  small  children. 

Bristowe  says  "  jejunal  and  iliac  intussusception  (i.  e.,  intus- 
susception of  the  small  intestine)  is  met  with  generally,  if  not 
exclusively,  in  adults." 

3d.  Ileo-cecal :  the  cecum  and  ileum  pass  into  the  colon,  but 
the  ileum  does  not  pass  through  the  valve. 

The  cecum  enters  the  colon,  dragging  the  ileum  with  it,  the 
ileo-cecal  valve  forming  the  lowest  end  of  the  tumor.  The 
cecum  and  the  upper  part  of  the  colon  are  gradually  inverted 
as  the  tumor  descends. 

This  variety  of  invagination  forms  forty-four  per  cent  of  all 
cases  both  in  adults  and  children.  It  probably  forms  between 
eighty  and  ninety  per  cent  of  all  the  cases  occurring  in  child- 
ren. 

4th.  Colic  invagination;  colon  passing  into  colon.  This 
forms  eight  per  cent  of  all  cases,  but  probably  a  larger  per  cent 
than  this  in  children. 

From  the  foregoing  it  will  be  seen  and  must  be  borne  in 
mind,  as  it  has  a  practical  bearing  on  the  treatment,  that,  in 


8  Forest  :  Intussusception  in  Children, 

nearly  every  case  of  intussuception  in  children,  the  colon  alone- 
forms  the  sheath  or  outside  layer  of  the  tumor,  and  that  the  in- 
vaginated  portion  of  the  intestine  can  be  acted  upon  by  a 
pressure  from  an  injection  thrown  into  the  colon. 

Cause. — The  cause  of  intussusception  is  given  as  unknown  in. 
sixty-two  per  cent  of  all  cases.  In  eight  per  cent  diarrhea  or 
dysentery  is  given  as  a  cause.  It  is  probably  due  in  every  case 
in  a  child  (when  there  is  no  polypus  or  malformation  of  the  in- 
testine) to  disturbed  nerve  action  in  the  intestine ;  a  want  of 
rhythm  of  action  between  the  circular  fibres  of  contiguous  parts 
of  the  intestine.  The  experiments  of  Nothnagel  are  interesting 
in  this  connection.  He  exposed  the  intestines  and  mesentery  in  a 
living  animal,  and  applied  the  faradic  electric  current  to  a  small 
area  of  the  mesentery.  A  portion  of  the  intestine  a  few  inches 
in  length,  connected  with  the  part  of  the  mesentery  acted  upon, 
contracted  firmly  into  a  dense  cord-like  condition.  The  intes- 
tine just  below  this  portion,  not  being  acted  upon  by  the  elec- 
tric current,  and  hence  retaining  its  natural  calibre,  gradually 
rose  up  around  the  contracted  intestine  and  inclosed  it,  thus 
forming  a  perfect  intussusception.  Now  apply  this  view  of  the 
cause  of  intussusception  to  the  human  subject.  A  child,  from 
some  one  of  the  many  possible  causes,  has  the  nervous  action  of 
the  intestine  disturbed ;  it  has  a  colic  in  fact,  a  wave  of  spasmodic 
contraction  and  relaxation  either  commences  near  or  travels, 
down  to  the  lower  end  of  the  ileum. 

The  cecum,  the  beginning  of  the  large  intestine,  is  large,  and 
in  the  child  very  movable.     As  the  ileum  near  the  valve  con- 
tracts spasmodically,  the  larger  cecum  slips  up  around  it  and 
the  intussusception  is  commenced.    Now  every  paroxysm  of  pain 
tends  to  increase  this  condition  by  pushing  the  ileum  further  and 
further  into  the  colon,  turning  the  upper  part  of  the    colon 
inside  out,  until  at  length,  in  severe  cases,  perhaps  in  a  few 
hours,  the  extremity  of  the  ileum,  with  the  ileo-cecal  valve,  will 
protrude  from  one  to  six  inches  outside  of  the  anus.    The  usual 
cause  of  intussusception  then  must  be  some  disturbance  of  nerve 
action  in  the  intestine.     However  interesting  this  theory  of  the 
cause  of  intussusception  may  be  from  a  scientific  standpoint,  it 
has  no  practical  bearing  whatever.     There    te  no   method   of 
knowing  when  the  child  is  in  danger  of  an  attack  of  intus- 
susception, for  in  many  cases  it  comes  on  apparently  in  a  mo- 


Forest  :   Intussusception  in  Children.  9 

ment,  in  children  that  seem  perfectly  healthy.  Weakly  chil- 
dren, and  those  subject  to  intestinal  troubles,  are  probably  more 
liable  to  it  than  others. 

Diagnosis. — The  diagnosis  is  a  subject  of  the  greatest  im- 
portance. In  reading  histories  of  cases  of  intussusception  as  we 
find  them  given  from  time  to  time  in  the  medical  journals,  one 
is  struck  with  the  fact  that  in  a  majority  of  the  cases  an  errone- 
ous diagnosis  is  made  at  first,  and  a  wrong  course  of  treatment 
pursued. 

Either  the  case  is  thought  to  be  one  of  obstinate  constipation 
and  is  treated  for  a  time  by  purgatives,  such  as  croton  oil,  calo- 
mel, jalap,  liquid  mercury,  or  bird-shot,  much  to  the  detriment 
of  the  patient ;  or,  on  the  other  hand,  it  is  thought  to  be  a  case 
of  severe  wind- colic  or  dysentery,  and  is  treated  with  opium. 

After  a  clay  or  two  of  such  treatment,  the  physician  either 
discovers  his  mistake,  or  some  one  is  called  in  who  recognizes 
the  true  state  of  the  case. 

Now  there  is  no  inherent  difficulty  in  making  a  diagnosis  of 
this  affection  in  children,  in  the  majority  of  cases.  Mistakes 
are  made,  because  the  physician  is  not  on  the  lookout  for  this 
condition,  and  because  the  symptoms  resemble  somewhat  cer- 
tain minor  affections. 

The  characteristic  symptoms  are  four :  pain,  bloody  dis- 
charges, tenesmus,  and  a  tumor.  The  pain  in  acute  cases  is 
paroxysmal  in  character,  is  sharp  and  cutting,  and  causes  the 
child  to  scream.  In  itself  this  is  not  characteristic,  but  taken 
with  the  next  symptom  it  becomes  of  great  importance.  A. 
discharge  of  blood  is  one  of  the  most  important  symptoms.  It 
appears  a  few  hours  after  the  attacks  of  pain,  and  is  almost  in- 
variably present  during  the  course  of  the  disease.  There  are 
but  three  affections  in  children  that,  so  far  as  I  know,  give  rise 
to  bloody  discharges  from  the  anus.  These  are  dysentery,  mu- 
cous polypi,  and  intussusception. 

Polypi  need  never  be  confounded  with  intussusception,  be- 
cause the  symptoms  are  not  acute,  and  they  are  not  accompanied 
with  cramp-like  pains,  and  constitutional  disturbances. 

The  diagnosis  between  intussusception  and  acute  dysentery  is 
a  little  more  difficult.  Dr.  J.  Lewis  Smith  says  that,  in  most  of 
the  cases  of  intussusception  where  he  has  been  called  in  con- 
sultation, he  lias  found  the  patient  under  treatment  for  dysen- 
terv. 


10  Forest:  Intussusception  in  Children. 

The  points  of  difference  are  that  there  is  more  blood  and 
little,  if  any,  slime  in  intussusception,  while  in  dysentery  there 
are  slimy,  foul-smelling  discharges,  tinged  with  blood.  In  in- 
tussusception the  attack  is  generally  more  acute  than  in  dysen- 
tery, the  pain  is  greater,  and  more  like  colic ;  finally,  there  is  a 
tumor  that  may  usually  be  found  by  a  careful  examination. 

Blood  is  always  present  in  these  cases  in  young  children,  but 
in  children  over  ten  years  of  age,  and  in  adults,  it  may  be  ab- 
sent. 

The  tumor  is  the  characteristic  sign.  This  is  present  and  can 
be  found  in  about  eighty  per  cent  of  all  cases,  and  in  children 
probably  in  a  much  greater  percentage  of  cases.  In  the  search 
for  the  tumor,  if  the  child  is  very  fleshy,  or  the  abdominal  wall 
resisting,  the  patient  may  be  safely  put  under  the  influence  of 
ether  or  chloroform. 

Generally  the  tumor  will  be  found  in  the  left  hypochondriac 
region.  The  location,  however,  is  not  constant  by  any  means, 
and  it  may  be  found  in  any  region  of  the  abdomen. 

The  tumor  is  oblong  in  shape ;  it  is  movable,  changes  its 
position  during  an  attack  of  pain,  and  is  erectile  to  a  certain 
extent  when  the  child  strains. 

Not  infrequently  the  tumor  appears  at  the  anus,  or  may  be 
reached  by  passing  the  finger  into  the  rectum. 

Is  it  possible  to  mistake  a  tumor  of  this  character,  when  asso- 
ciated with  some  or  all  of  the  symptoms  previously  mentioned, 
for  anything  but  an  invagination  ?  The  pain,  the  blood,  the 
constitutional  reaction,  the  throes  and  strainings  of  the  child 
without  passing  feces,  and  the  erectile  tumor  are  the  practical 
signs.  Not  all  of  them  may  be  present  in  every  case,  but  some 
of  them  must  be. 

There  are  other  symptoms  of  intussusception,  but  they  are  by 
no  means  so  characteristic  as  those  just  given.  Yomiting  is 
usually  present,  but  this  is  so  frequently  present  in  children's 
diseases  that  it  is  no  guide  for  the  diagnosis  of  intussusception. 

In  the  cases  I  have  seen,  there  was  a  marked  relaxation  of 
the  sphincter  ani :  in  children  less  than  a  year  old,  two  fingers 
passed  easily  into  the  rectum. 

This  symptom  points  to  some  affection  of  the  large  intestine. 

With  many  or  all  these  symptoms  present,  there  will  be  little 
trouble  in  making  a  diagnosis,  if  the  physician  is  ready  to  ap- 
preciate the  meaning  of  them. 


Forest  :  Intussusception  in  Children.  11 

In  subacute  and  chronic  cases,  these  symptoms  mentioned 
above  are  not  so  prominent.  There  may  not  be  great  pain ;  a 
paroxysm  not  very  severe  is  succeeded  by  a  long  interval  of 
ease ;  constipation  may  not  be  present  for  some  time ;  blood 
will  appear  at  the  anus  after  a  time,  and  careful  search  will  dis- 
cover a  tumor  somewhere  in  the  abdomen.  But  on  account  of 
the  comparative  rarity  of  the  disease,  and  the  lack  of  urgency 
in  the  symptoms,  a  careful  examination  of  the  abdomen  may  not 
be  made,"  and  hence  a  mistaken  diagnosis  is  held  for  severa 
days.  The  only  way  to  avoid  these  mistakes  is,  in  every  case  of 
colic  or  bloody  discharges  in  a  child,  to  make  a  very  careful 
manipulation  of  the  abdomen  for  the  possible  presence  of  a 
tumor.  The  importance  of  making  an  early  diagnosis  in  this 
affection  must  be  evident. 

Treatment. — In  the  treatment  of  this  affection  drugs  play  an 
altogether  secondary  part.  Cathartics,  of  course,  are  contra-in- 
dicated. 

The  English  authors  speak  of  belladonna  and  opium  as  being 
useful,  the  belladonna  to  relax  the  intestinal  spasm  and  to  re- 
store the  rhythmical  action  of  the  unstriped  muscular  fibre;  the 
opium  to  relieve  pain  and  prevent  shock.  The  uncertainty  as 
to  how  much  opium  may  be  given  with  safety  to  a  child  makes 
me  afraid  to  use  it  to  any  extent  in  this  affection,  though  I 
should  certainly  give  it.  It  will  require  a  poisonous  dose  to  re- 
lieve the  pain  of  intussusception,  and  if  the  tumor  should  be 
reduced  while  the  opiate  is  yet  in  the  system,  death  might  occur 
from  opium  poisoning.  A  small  dose  frequently  repeated,  to 
counteract  shock  and  quiet  intestinal  action,  may  be  safely 
given,  but  for  the  relief  of  pain  and  spasm  during  attempts  at 
reduction,  chloroform  or  ether  will  be  safer  and  more  servicea- 
ble than  opium. 

Spontaneous  cure  by  sloughing  of  the  invaginated  portion  of 
the  intestines  is  hardly  worth  considering  in  the  case  of  chil- 
dren under  five  years  of  age.  Bristowe  speaks  somewhat  doubt- 
fully of  the  value  of  active  treatment  in  this  affection,  and  says 
that  we  may  well  give  the  child  the  chance  of  recovery  by  sponta- 
neous cure.  But  he  likewise  says  that  if  the  invagination  oc- 
curs in  the  large  intestine,  recovery  by  sloughing  almost  never 
takes  place  ;  and  in  another  connection  he  says  that  intussuscep- 
tion in  children  rarely,  if  ever,  occurs,  except  in  the  large  in- 
testines. 


12  Forest  :  Intussusce2)tio?i  in  Children. 

Putting  these  statements  together,  it  becomes  plain  that 
chilclen,  unlike  adults,  can  rarely  recover  spontoneously. 

Treves'  statistics  show  that  spontaneous  elimination  of  the 
invaginated  intestine  in  children  under  two  years  of  age  takes 
place  in  only  tico  per  cent  of  the  cases.  Even  in  the  cases  of 
spontaneous  elimination  the  child  very  rarely  recovers,  but  dies 
from  peritonitis  or  exhaustion.  Between  two  and  five  years  of 
age,  spontaneous  elimination  (not  cure)  takes  place  in  only  six 
per  cent  of  the  cases  ;  between  six  and  ten  years  of  age  in 
thirty-eight  per  cent.  Hence,  active  treatment  of  some  kind  is 
indicated.  Bearing  in  mind  what  has  been  said  previously  as 
to  the  usual  location  of  the  disease  in  children,  it  will  at  once  be 
plain  that  pressure  on  the  tumor  by  injections  through  the  colon 
will  be  a  reasonable  method  of  treatment.  This  treatment  is 
as  old  as  Hippocrates. 

There  are  several  things  to  be  considered  before  giving  an 
injection  for  intussusception. 

1st.  When  does  adhesion  between  the  coats  of  the  invagi- 
nated intestine  take  place  ;  for,  obviously,  it  would  not  be  safe  to 
try  to  force  back  the  tumor  after  adhesion  and  sloughing 
had  commenced.  The  very  shortest  time  on  record  when 
adhesions  had  taken  place  between  the  coats  of  the  invagi- 
nated intestine  is  three  days.  The  average  length  of  time  is. 
five  to  seven  days.  Even  then  these  recent  adhesions  are  soft 
and  yield  to  pressure,  and  are  not  a  bar  to  careful  attempts  at 
reduction. 

2d.  When  does  softening  and  sloughing  of  the  bowel  com- 
mence in  these  cases?  This  very  important  question  cannot  be 
definitely  answered.  The  time  varies  remarkably.  In  the  ultra 
acute  cases  (which  happily  are  very  rare)  sloughing  may  com- 
mence in  twenty-four  hours.  In  the  ordinary  acute  cases  three 
days  would  be  about  the  minimum  time.  In  subacute  cases  a 
week  or  more  may  pass  before  sloughing  takes  place. 

3d.  What  form  of  injection  is  the  best :  liquid,  or  gas,  or  a 
combination  of  them  both ;  and  how  shall  the  injection  be  best 
administered  ? 

In  answer  to  this  I  can  say  that  I  found  the  siphon  arrange- 
ment I  have  described  very  convenient  and  effective  in  the 
cases  in  which  I  used  it.  Certain  facts  about  these  siphons 
should  be  borne  in  mind  before  employing  them.  They  contain 
either  saline  or  pure   water  charged  with  carbonic  acid  gas- 


Forest  :  Intussusception  in  Children.  13 

Thev  are  charged  under  a  pressure  of  from  one  hundred  to  one 
hundred  and  twenty  pounds  to  the  square  inch.  Each  cubic 
inch  of  water  under  this  pressure  absorbs  about  five  cubic 
inches  of  gas,  four  inches  of  which  will  be  liberated  as  soon  as 
the  water  escapes  from  the  pressure  within  the  siphon.  Hence 
when  one  cubic  inch  of  water  has  escaped  from  the  siphon  into 
the  bowel  we  have  in  reality  given  a  volume  of  gas  and  liquid 
that  occupies  space  equivalent  to  five  cubic  inches.  Hence 
the  liquid  should  be  allowed  to  escape  very  slowly,  barely  a 
drachm  or  two  at  a  time  ;  we  must  bear  in  mind  that  we  have 
a  force  in  the  bottle  sufficient  to  rupture  the  intestine  instantly 
if  employed  carelessly.  Another  caution  to  be  observed  in  the 
use  of  the  siphon  is  to  avoid  exposing  it  to  any  considerable 
heat  in  warming  it,  for  fear  of  an  explosion. 

It  may  be  said  that  the  siphon  cannot  always  be  obtained 
when  needed,  especially  in  country  districts.  If  the  siphon  is 
not  at  hand,  one  can  be  improvised  in  fifteen  minutes  in  the 
following  manner :  Take  a  strong  bottle  or  jug  holding  a  pint 
of  water.  Fill  it  and  then  put  in  two  ounces  of  bicarbonate  of 
soda  and  an  ounce  and  a  half  of  tartaric  acid.  Cork  instantly, 
tie  in  the  cork,  cover  with  melted  sealing-wax,  and  then  screw  a 
champagne  faucet  through  the  cork.  By  slipping  the  rubber 
tube  over  the  faucet  and  inverting  the  bottle  we  have  a  siphon 
that  answers  every  purpose. 

Ziemssen  speaks  very  highly  of  carbonic  acid  gas  in  the  treat- 
ment of  intussusception.  He  seems  to  think  it  has  some  specific 
effect  on  the  coats  of  the  intestine  that  favors  the  reduction  of 
the  invagination. 

He  recommends  a  measure  in  the  use  of  it  that  cannot  be 
employed  with  safety,  in  children  at  least.  He  says  that 
twenty  grains  of  bicarbonate  of  soda  may  be  dissolved  and  in- 
jected into  the  rectum.  Then  fifteen  grains  of  tartaric  acid 
in  solution  may  be  injected.  The  chemical  union  of  the  two 
will  set  free  a  large  volume  of  carbonic  acid  gas  within  the  colon. 

4th.  What  syringe  should  he  used  f  After  a  careful  con- 
sideration of  the  subject  and  many  experiments,  I  have  become 
satisfied  that  we  should  use  the  fountain  syringe  only  in  treating 
these  cases. 

The  surgeon  should  know  exactly  how  much  force  he  is 
exerting  on  the  walls  of  the  intestine  every  moment.  If  accu- 
racy is  important  in  any  surgical  operation,  it  is  important  in  this 


14  Forest:  Intussusception  in  Children. 

one.  The  danger  is  not  greater  in  using  too  much  force  than  in 
using  too  little.  In  the  former  case,  the  intestine  is  ruptured 
and  death  ensues  ;  in  the  latter,  the  injection  having  been  tried 
with  too  little  force,  the  tumor  is  wrongly  declared  irreducible 
by  injection,  and  the  child  is  left  to  die  unaided,  or  it  is  at  once 
decided  that  an  operation  by  laparotomy  is  the  only  resource. 

To  illustrate  how  absurdly  injections  are  often  given  in  these 
cases,  let  me  give  the  outlines  of  a  case  reported  in  the  Mary- 
land Med.  Journal  for  December,  1884 : 

A  surgeon  was  called  in  consultation  in  a  case  of  intussuscep- 
tion in  a  child  two  years  of  age.  He  says  that  in  attempting  to 
reduce  the  invagination  by  injections,  the  child  was  inverted  and 
a  funnel  inserted  into  the  rectum  and  water  poured  into  this. 
This  method  failing  to  reduce  the  tumor,  and  the  parents  not  con- 
senting to  the  operation  of  laparotomy,  the  child  was  left  alone. 
At  length  the  parents  consented  to  the  operation  ;  the  abdomen 
was  opened  and  the  tumor  easily  reduced.  The  child,  however,, 
died  from  exhaustion  and  shock. 

The  surgeon  reporting  the  case  draws  the  moral  that  the 
operation  of  laparatomy  should  be  resorted  to  early  in  these, 
cases.  It  does  not  occur  to  him  that  a  pressure  from  within 
the  colon  against  the  tumor  by  liquid  or  gas  injected  with 
sufficient  force  might  have  done  in  the  beginning  what  his  fin- 
gers in  the  abdominal  cavity  did  two  days  later,  namely,  reduced 
the  non-adherent  tumor.  A  force  of  possibly  a  half  pound  pres- 
sure to  the  square  inch  was  employed  by  his  injection,  when  he 
might  have  used  with  safety,  and  should  have  tried  at  least,  a 
pressure  of  five  or  six  pounds  to  the  square  inch,  before  deciding 
that  injections  were  useless. 

Another  case  was  reported  in  the  JV.  Y.  Med.  Journal  a  few 
years  ago.  The  physician  says  :  "  I  at  once  suspected  it  to  be  a 
case  of  intussusception"  (the  tumor  was  present  and  every 
symptom  needed  to  make  a  positive  diagnosis)  "  and  ordered  an 
enema  of  tepid  soap  and  water  to  be  repeated  every  two  or  three 
hours  until  a  fecal  discharge  should  be  obtained.  On  my  return 
next  morning  I  was  informed  that  no  passage  had  been  pro- 
duced." Injections  thus  administered  do  not  tend  to  force  back  the; 
invagination,  but  to  increase  it.  The  colon  is  stimulated  to  make 
expulsive  efforts  and  thus  drive  the  intestinal  tumor  further 
down. 

The  Davidson 's  syringe,  the  usual  means  used  in  giving  injec- 
tions for  the  cure  of  intussusception,  is  a  wholly  untrustworthy; 


Forest  :  Intussusception  in  Children.  15* 

instrument  and  should  never  be  used  if  the  fountain  syringe  can 
be  obtained.  The  amount  of  force  evolved  by  compressing  the 
bulb  of  the  Davidson  syringe  depends  on  the  muscular  power  of 
the  operator,  and  cannot  be  even  approximately  measured.  In 
one  case  it  may  be  enough  to  rupture  the  intestine  instantly,  and 
in  another  not  as  much  as  might  have  been  used  with  perfect 
safety. 

Surgeons  would  perhaps  be  surprised  did  they  know  how 
much  force  can  be  obtained  from  the  Davidson's  syringe.  I  find 
that  the  grasping  power  of  my  own  hand  as  measured  by  the 
dynamometer  is  about  ninety  pounds.  Now,  apply  this  force  to 
the  bulb  of  a  Davidson's  syringe,  and  if  the  syringe  be  a  good 
one,  we  can  bring  to  bear  on  a  column  of  water  within  the  colon 
a  pressure  of  ninety  pounds  to  the  square  inch,  provided,  of 
course,  the  colon  does  not  rupture.  Experiments,  given  later, 
show  that  it  will  usually  rupture  under  a  pressure  of  fifteen 
pounds  to  the  square  inch.  Hence  with  the  Davidson's  syringe 
the  surgeon  does  not  know  whether  he  is  exerting  a  pressure  of 
five  or  thirty  pounds  to  the  square  inch  in  the  colon.  This 
syringe,  then,  is  not  an  instrument  of  precision  at  least.  Then 
again  the  intermitting  force  given  from  the  Davidson's  syringe 
is  objectionable.  It  tends  to  excite  peristaltic  action  in  the  in- 
testines which  should  be  avoided  as  much  as  possible. 

Injection  of  air :  insufflation  by  means  of  a  bellows  is  fre- 
quently practised  in  England  in  the  treatment  of  these  cases 
This  method  is  open  to  the  same  objections  and  on  the  same 
grounds  as  the  treatment  by  the  Davidson's  syringe. 

Bryant,  of  London,  reports  a  number  of  cases  where  the  intes- 
tines were  ruptured  by  insufflation  from  a  bellows.  This  method, 
then,  is  not  unaccompanied  with  danger. 

A  still  more  dangerous  instrument  is  the  one  that  succeeded 
in  cases  I.  and  II.  reported  by  me,  namely,  the  siphon  of  Vichy 
or  carbonic  acid  water.  I  am  surprised  to  find  that  Treves,  in 
recommending  this  method  of  treatment,  gives  not  one  word  of 
caution  as  to  the  dangers  to  be  guarded  against.  The  precautions 
to  be  used  are  given  on  a  preceding  page  and  need  not  be  re- 
peated here. 

The  most  dangerous  method  of  all  in  the  treatment  of  these 
cases  is  that  recommended  by  Ziemssen,  namely,  to  first  inject 
a  solution  of  bicarbonate  of  soda,  and  then  immediately  to  inject 
a  solution  of  tartaric  acid  so  as  to  set  free  carbonic  acid  gas  by 


16  Forest  :  Intussuscep>tion  in  Children. 

their  union.  This  may  not  be  as  dangerous  as  exploding  dyna- 
mite within  the  intestine,  but  the  same  principle  is  employed  in 
producing  force  in  either  case,  namely,  a  rapid  chemical  change 
with  a  sudden  liberation  of  gas. 

The  fountain  syringe,  then,  is  the  only  one  that  can  be  used 
in  these  cases  with  accuracy,  and  therefore  it  is  the  only 
one  that  should  be  employed.  By  it  the  amount  of  force  used 
can  be  accurately  measured,  as  every  two  and  one-half  feet  in 
/(eight  of  the  reservoir  above  the  point  of  delivery  'represents 
about  one  pound  pressure  on  every  square  inch  of  the  intestine 
helow  the  p>oini  of  obstruction.  Tims  if  the  reservoir  is  sus- 
pended seven  and  one-half  feet  above  the  child,  a  force  of  three 
pounds  to  the  square  inch  is  exerted  on  the  obstruction.  If  the 
rubber  tube  be  tifteen  feet  in  length  and  vertical,  the  pressure 
will  be  six  pounds  to  the  square  inch.  With  a  tube  of  sufficient 
length  any  pressure  can  be  brought  to  bear  on  the  tumor  as  de- 
sired. This  law  of  the  relation  of  pressure  to  height  comes  from 
the  well-known  physical  fact  that  our  atmosphere,  weighing 
fourteen  and  three-fourths  pounds  to  the  square  inch,  balances  a 
column  of  water  thirty-four  feet  high.  Hence  each  pound  of 
the  atmosphere  balances  a  column  of  water  2.37  feet  in  height. 
It  will  be  accurate  enough  for  all  practical  purposes  to  say  then 
that  a  column  of  water  two  and  one-half  feet  high  exerts  at  its 
base  in  every  direction  a  pressure  of  one  pound  to  the  square 
inch.  Hence  the  exact  force  used  in  giving  an  injection  can  be 
obtained  in  this  manner.  The  only  important  feature  about  the 
siphon  syringe  is  the  long  tube,  or  a  number  of  pieces  of  rub- 
ber tubing  that  can  be  spliced. 

Not  less  than  from  twelve  to  twenty  feet  of  tubing  should  be 
at  hand.  The  reason  for  this  will  appear  later.  Into  the  upper 
end  of  the  tubing  a  funnel  can  be  inserted  in  which  to  pour  the 
water ;  or  the  water  can  be  conducted  into  the  tube  from  an  or- 
dinary pitcher  on  the  principle  of  the  siphon. 

A  convenient  way  of  getting  sufficient  elevation  (for  most 
rooms  are  not  twelve  to  twenty  feet  high)  would  be  to  have  one 
person  carry  the  reservoir  of  water  to  the  stairway  while  the 
patient  could  be  in  the  hall-way  or  in  a  room  opening  into  the 
hall  near  the  stairs.  I  have  dwelt  at  some  length  on  these 
details  because  it  can  only  be  by  paying  attention  to  them  that 
we  can  treat  intussusception  successfully  by  means  of  injec- 
tions. 


Forest  :  Intussusception  in  Children.  17 

Whether  one  use  the  Davidson's  syringe  in  giving  the  injec- 
tion or  the  siphon,  the  recal  tube  I  have  described  as  made 
from  a  glass  vaginal  syringe  with  a  shoulder  one  inch  from  the 
end  will  be  found  a  very  important  adjunct.  By  this  simple 
contrivance  an  injection  may  be  given  without  fear  of  wound- 
ing the  intestine,  without  making  painful  pressure  on  the  parts 
about  the  anus,  without  the  escape  of  a  drop  of  the  liquid  used, 
and  with  the  utmost  ease  and  convenience  to  the  operator.  Its 
effectiveness  is  clue  to  the  fact  that  during  the  terrible  expulsive 
efforts  of  the  patient  the  stretched  sphincter  is  supported  by 
the  large  tube  and  the  shoulder,  and  thus  none  of  the  liquid 
used  can  escape.  Owing  to  this  fact  we  can  measure  accurately 
how  large  a  quantity  of  liquid  is  injected.  A  shoulder  on  the 
nozzle  of  the  Davidson's  syringe  will  not  answer  the  same  pur- 
pose at  all,  because  the  diameter  of  the  nozzle  is  only  about  a 
quarter  of  an  inch  and  hence  does  not  support  the  relaxed 
sphincter. 

Mr.  Lund,  of  Manchester,  England,  has  devised  a  rather 
elaborate  instrument  for  this  purpose,  consisting  of  a  nozzle  like 
that  of  a  Davidson's  syringe,  an  air-inflated  rubber  ring  on  it  to 
press  against  the  anus,  a  metallic  shoulder  to  support  the  rub- 
ber ring,  a  double  canula,  and  a  handle  to  hold  the  whole  by. 
This  ajDparatus,  which  Treves  figures  and  speaks  very  highly  of, 
is  not  so  simple,  so  cheap,  so  safe,  or  so  effective  as  the  one  de- 
vised by  me.  So  far  as  I  know,  this  instrument,  if  I  may  so 
designate  a  very  homely  and  simple  contrivance,  has  not  been 
before  used  in  these  cases.  A  trial  of  it  alone  can  show  its 
value. 

5th.  How  much  force  may  he  safely  used  in  giving  the  in- 
jection, provided  we  do  not  think  sloughing  has  commenced  f 

I  shall  have  to  disagree  with  Dr.  H.  B.  Sands  in  his  views  on 
this  point.  He  says  in  the  JSf.  Y.  Medical  Journal  for  1877 : 
"  If  injection  or  insufflation  causes  severe  pain,  it  should  be  con- 
sidered as  dangerous."  This  rule,  of  course,  could  not  be 
applied  if  the  child  was  under  the  influence  of  opium  or 
an  anesthetic,  and  one  or  the  other  should  be  used  in  most 
cases.  Then,  again,  the  greatest  pain  experienced  by  the  child 
and  the  most  violent  struggles  take  place  at  the  beginning  of 
treatment,  especially  if  the  tumor  be  in  the  lower  part  of  the 
colon. 

When  the  injection  is  properly  given,  especially  if  the  nozzle 


18  Forkst:  Intussusception  in  Children. 

I  hare  described  be  used,  it  will  be  found  in  most  cases  that 
the  pain  becomes  less  as  the  force  of  the  injection  is  increased, 
up  to  of  course  a  safe  limit.  It  was  so  in  the  cases  I  have  re- 
ported in  this  paper  and  it  is  so  given  in  reports  of  other  cases. 

My  answer  to  the  question  would  be  that  a  pressure  of  six 
pounds  to  the  square  inch  may  be  employed  in  any  case  seen 
within  three  or  four  days  of  the  inception  of  the  attack,  pro- 
vided, of  course,  that  a  lesser  pressure  does  not  succeed.  This 
pressure  could  be  reached  very  gradually  by  elevating  the  reser- 
voir up  to  a  height,  if  necessary,  of  fifteen  feet  above  the  patient. 
My  reasons  for  deciding  upon  this  particular  amount  of  force 
as  the  limit  to  which  we  may  go,  if  a  lesser  force  does  not  suf- 
fice, will  appear  from  the  following  experiments. 

Experiment  I. — Child  ten  days  old,  died  of  marasmus  not 
accompanied  with  any  fever.  Opened  the  abdomen  without 
disturbing  the  intestine.  Injected  cold  water  from  a  fountain 
syringe,  the  reservoir  suspended  five  and  one-half  feet  above  the 
point  of  delivery,  this  giving  a  pressure  of  a  little  over  two 
pounds  to  the  square  inch  within  the  intestine.  The  liquid  dis- 
tended the  colon  and  penetrated  to  the  ileo-cecal  valve,  but  did 
not  pass  that  point.  Manipulating  the  intestine  so  as  to  make 
slight  traction  on  the  ileum  at  its  point  of  junction  with  the 
cecum,  opened  the  valve  so  that  the  liquid  passed  easily  while 
the  pressure  remained  as  before. 

Suspending  the  child  by  the  feet,  with  the  head  downwards, 
also  made  the  ileo-cecal  valves  pervious,  without  increasing  the 
pressure. 

These  experiments  would  seem  to  show  that  massage  and  po- 
sition may,  in  some  cases,  aid  in  opening  the  ileo-cecal  valve  to 
the  passage  of  an  injection. 

Experiment  IL—  Reservoir  suspended  nine  feet  above  the  point 
of  delivery,  thus  making  the  pressure  within  the  colon  about 
four  pounds  to  the  square  inch.  This  caused  the  liquid  to  pass 
the  valve  when  aided  by  the  position  of  the  child,  with  its  head 
downwards. 

The  liquid,  however,  did  not  penetrate  beyond  the  middle  of 
the  small  intestine,  owing  to  the  friction  in  the  small  intestine 
and  the  obstruction  from  numerous  sharp  turns.  Experiment 
repeated  several  times,  with  the  same  result  each  time.  The 
practical  deductions  from  this  experiment  would  be,  that  the 
pressure  from  the  rectal  injection  will  always  be  greater  in  the 


Fokest  :  Intussusception  in  Children.  19 

colon  than  in  the  small  intestine,  and  the  pressure  in  the  small 
intestine  will  decrease  directly  as  the  distance  from  the  ileo- 
cecal valve. 

An  obstruction  in  the  small  intestine,  especially  if  it  be  in 
the  upper  half,  can  only  be  overcome  by  the  expenditure  of  great 
force  at  the  rectum. 

Experiment  III. — Used  the  siphon  apparatus  described  in 
the  first  part  of  this  paper.  The  liquid  and  ,gas  were  al- 
lowed to  escape  very  slowly.  The  colon,  intestines,  and  stomach 
were  each  dilated  in  turn,  and  in  a  few  minutes  the  gas  bubbled 
out  of  the  subject's  mouth  and  nose.  It  seemed  almost  impos- 
sible to  rupture  the  intestine  by  pressure,  as  long  as  the  nose 
or  mouth  were  pervious. 

Experiment  IV. — A  ligature  was  placed  about  the  small  in- 
testine five  feet  from  the  ileo-cecal  valve;  when  the  pressure  be- 
came too  strong  -to  be  resisted,  the  intestine  gave  way,  not  at  the 
point  of  obstruction  in  the  small  intestine,  but  in  the  middle  of 
the  transverse  portion  of  the  colon. 

Experiment  V. — Child  three  weeks  old,  dead  three  days. 
Pressure  from  a  fountain  syringe,  equal  to  five  pounds  to  the 
square  inch,  was  put  upon  the  colon  without  rupturing  it  or 
even  destroying  its  elasticity.  This  pressure,  however,  did  not 
force  the  water  through  the  ileo-cecal  valve  (as  did  a  less  pres- 
sure in  the  other  case),  although  position  of  the  child  and  ma- 
nipulation of  the  intestines  were  used  as  aids  to  the  injection. 

Experiment  VI. — By  the  courtesy  of  Dr.  Taft,  chemist 
for  John  Matthews,  I  had  been  furnished  with  a  five-gallon 
fountain  filled  with  water  and  charged  with  carbonic  oxide  gas, 
under  a  pressure  of  fifty  pounds  to  the  square  inch.  The  de- 
livery pipe  from  the  fountain  had  a  pressure  gauge  so  arranged 
on  it  that  the  gauge  measured  the  pressure  in  the  delivery  tube 
at  any  given  moment.  Xow,  when  'this  tube  was  connected 
with  the  rectum  by  means  of  the  nozzle  of  the  syringe,  and  the 
stop-cock  slowly  opened,  the  gauge  measured  the  pressure  upon 
each  square  inch  of  the  colon  at  any  instant.  TVhen  all  was 
read}*,  the  water  and  gas  were  allowed  to  escape  slowly  from 
the  fountain  and  thus  to  gradually  increase  the  pressure  in  the 
colon.  The  gas  causes  a  more  rapid  and  forcible  dilatation  of 
the  intestines  than  does  a  liquid,  even  under  the  same  pressure. 
A  force  of  six  pounds  to  the  square  inch  was  used  without  fore- 


20  Forest  :  Intussusception  in  Children. 

ing  the  ileocecal  valve,  and  without  rupturing  or   even  over- 
distending  the  colon. 

Experiment  VII. — The  bands  of  the  peritoneum  binding 
the  ileum  to  the  colon  at  the  ileo- cecal  valve  were  divided 
without  cutting  any  of  the  muscular  coats  of  the  intestine. 
Tliis  allowed  the  end  of  the  ileum  to  be  drawn  out  from  the 
colon  and  destroyed  the  integrity  of  the  valve. 

Experiment  VIII. — Made  an  impassable  obstruction  in  the 
small  intestine  by  means  of  a  ligature,  and  then  turned  the 
stop-cock  so  as  to  allow  the  pressure  to  slowly  increase  in  the 
intestine  up  to  the  point  of  rupture.  Rupture  took  place  at 
about  the  middle  of  the  transverse  colon  on  the  anterior  surface. 
The  intestine  bore  a  pressure  of  nine  and  three-quarter  pounds 
to  the  square  inch  before  rupturing.  The  subject  was  a  child 
a  few  months  old. 

It  may  be  said  here  that  rupture  in  all  the  experiments  took 
place  in  the  colon,  and  usually  in  the  transverse  colon.  This 
shows,  not  that  the  colon  has  less  resistance  than  the  small  in- 
testine, but  that  in  a  rectal  injection  the  pressure  must  always 
be  greater  in  the  colon  than  in  the  small  intestine,  even  though 
the  valve  be  pervious. 

Experiment  IX. — Male  about  forty  years  of  age  ;  died  of 
cirrhosis  of  liver.  Connected  the  colon  with  the  carbonic  acid 
fountain  and  allowed  the  colon  to  fill  slowly.  When  the  gauge 
indicated  a  pressure  of  nine  pounds  to  the  square  inch,  the  gas 
passed  the  ileo-cecal  valve. 

At  a  pressure  of  thirteen  and  one-half  pounds  to  the  square 
inch  the  longitudinal  bands  on  the  colon  that  give  it  its  charac- 
teristic appearance  gave  way  in  places  with  a  snap.  The  pressure 
was  allowed  to  run  up  to  fifteen  pounds  to  the  square  inch,  and 
still  the  intestine  did  not  rapture.  The  gas  and  water  passed 
freely  through  the  whole  length  of  the  intestinal  canal  and  out 
of  the  mouth. 

Experiment  X. — Eight  months'  fetus  that  died  during  de- 
livery. A  pressure  of  two  pounds  to  the  square  inch  forced 
liquid  through  the  ileo-cecal  valve,  and  a  short  distance  into  the 
small  intestine.  A  pressure  of  three  and  one-half  pounds 
forced  the  liquid  through  the  whole  length  of  the  alimentary 
canal  and  out  of  the  mouth.  A  ligature  was  placed  around  the 
intestine  at  about  the  junction  of  the  jejunum  and  ileum,  and 
the  intestines  subjected  to  a  pressure  of  six  pounds  to  the  square 


Forest:   Intussusception  in  Children.  21 

inch.     There  was  no  rupture.     It  would  seem  from  these  few 
experiments  that  the  following  conclusions  might  be  drawn  : 

a.  That  position  and  manipulation,  in  some  cases  at  least^ 
aid  in  forcing  an  injection  through  the  ileo-cecal  valve. 

b.  That  in  most  cases,  not  in  all,  the  valve  will  give  way  so 
as  to  permit  of  the  passage  of  an  injection  before  a  rupture  of 
the  colon  would  take  place. 

c.  That  the  valve  is  not  the  only  obstacle  to  the  passage  of 
liquids  or  gas  from  the  anus  to  the  mouth,  but  that  friction  in 
the  small  intestine  is  an  important  factor. 

d.  That  if. an  injection  be  given  with  force  sufficient  to 
cause  rupture  of  the  gut,  the  rupture  will  occur  in  the  colon. 

e.  Injections  cannot  be  relied  upon  to  overcome  obstruc- 
tions in  the  small  intestine. 

f  That  the  colon,  both  in  the  child  and  in  the  adult,  bears 
a  surprising  amount  of  pressure  without  rupture,  a  force  of 
eight  or  nine  pounds  in  the  infant,  to  twelve  or  fifteen  pounds 
in  the  adult. 

These  latter  conclusions  are  the  ones  that  concern  us  most  in 
this  inquiry.  We  would  then  be  justified,  in  any  case  of  intus- 
susception in  a  child,  where  the  disease  has  not  lasted  long 
enough  for  sloughing  to  commence,  or  adhesions  to  form,  to 
gradually  apply  a  pressure  within  the  colon  of  at  least  six  pounds 
•to  the  square  inch.  This  could  be  done  by  raising  the  reservoir 
.about  fifteen  feet  above  the  subject  operated  on. 

If  the  invagination  be  reducible,  this  pressure  would  seem  to 
be  sufficient  in  any  ordinary  case  to  reduce  it,  for  it  must  be 
borne  in  mind  that  practically  the  intussusception  in  children  is 
always  in  the  large  intestine,  and  so  will  receive  the  full  force 
of  the  injection.  A  pressure  of  six  pounds  to  the  square  inch  is 
a  safe  force  to  use  in  any  acute  cases  seen  within  the  first 
three  days.  If  the  case  be  subacute  or  chronic,  this  pressure 
would  be  safe  to  employ  for  any  time  within  a  week,  or  perhaps 
three  weeks.  Cases  are  rejDorted  where  an  injection  has  suc- 
ce  eded  in  reducing  the  invagination  as  late  as  a  week  after  the 
aff  ection  appeared. 

6th.  How  shall  the  injection  be  given  %  Keep  up  a  very  slow 
o  ut  steadily  increasing  pressure  until  the  tumor  gives  way  or 
th  e  safe  limit  of  pressure  be  reached  without  reducing  the  in- 
v  agination.  Then  keep  the  pressure  at  this  point,  fifteen, 
t  wanty,    sixty  minutas,   if    necessary,  meantime   manipulating 


22  Forest  :  Intussusception  in  Children. 

the  abdomen  gently.  Of  course,  if  the  case  be  thus  obstinate, 
the  child  should  be  under  the  influence  of  ether. 

I  am  aware  that  this  continuous  pressure  is  not  the  method 
usually  practised  or  taught. 

We  are  told  to  inject  as  much  liquid  as  we  can,  and  then  let 
it  ran  out.  Then  repeat  the  maneuvre.  Tins  method  is 
admirable  for  exciting  the  large  intestine  to  expel  any  offending 
substance  from  it,  whether  that  be  hardened  feces  or  the 
invaginated  intestine.  Our  object,  however,  is  not  to  cause 
the  expulsion  of  anything,  but  to  mechanically  force  back  an 
intestinal  tumor. 

Therefore,  it  seems  evident  that  a  continuous  pressure  will 
acconrplish  this  result  better  than  an  intermittent  one.  It  will 
be  observed  in  case  I.  in  the  paper  that  the  intermittent  pres- 
sure from  the  Davidson  syringe  did  absolutely  no  good ;  on 
the  other  hand,  the  continuous  pressure  from  the  siphon,  with- 
out the  escape  of  any  of  the  injected  liquid,  soon  stopped  the 
pain  and  straggles  of  the  child,  and  steadily  forced  back  the 
tumor.  It  overcame  the  spasmodic  expulsive  efforts  as  the  con- 
tinuous but  gentle  pressure  of  the  sound  overcomes  spasm  of 
the  urethra  in  the  male. 

I  regard  this  principle  of  continuous  pressure  as  a  very  im- 
portant one  in  these  cases,  and  one  that  both  experience  and  the 
laws  of  hydrostatics  would  seem  to  indicate.  In  order  to  realize 
the  full  value  of  this  principle,  it  must  be  borne  in  mind  that 
hydraulic  pressure  is  always  the  same  in  every  direction.  Hence 
when  a  column  of  water  is  put  into  the  colon  in  these  cases  under 
a  certain  pressure,  it  not  only  is  pushing  back  the  tumor,  but  at 
the  same  time,  and  with  exactly  the  same  force,  it  is  dilating  the 
sheath  of  the  tumor  and  compressing  the  tumor  on  every  side, 
and  thus  lesssening  its  calibre  ;  even  for  this  reason  alone,  if  for 
no  other,  the  pressure  should  be  continuous  instead  of  intermit- 
tent, until  the  object  in  giving  the  injection  is  obtained. 

There  can  be  nothing  gained  in  such  a  case  by  forcing  back 
the  tumor  for  a  short  distance  and  then  allowing  it  to  be  pushed 
clown  again  by  an  expulsive  effort. 

If  continuous  pressure  be  used,  the  injected  liquid  might  be 
warm  milk,  or  milk  and  water,  or  beef-tea,  as  in  the  fifteen  to 
sixty  minutes  that  this  would  be  contained  in  the  colon,  a  not 
inconsiderable  amount  would  be  absorbed,  and  thus  aid  to  keep 
up  the  vital  powers  of  the  child. 


Forest  :  Intussusception  in  Children.  23 

But  suppose  that  this  plan  of  treatment  has  been  faithfully 
-tried  and  still  the  case  does  not  yield  to  the  treatment ;  what  is 
to  be  done  % 

There  are  three  courses  open  :  First.  An  operation  by  laparot- 
omy, opening  the  abdomen  and  attempting  to  reduce  the  invag- 
ination by  traction  on  the  intestine. 

Second.  Leaving  the  case  to  nature,  with  the  chance  of  a  cure 
by  spontaneous  elimination  of  the  invaginated  portion  of  the 
intestine ;  or, 

Third.  The  use  of  a  more  forcible  injection,  even  though 
there  be  the  possibility  of  rupturing  the  intestine  by  so  doing. 

Let  us  consider  these  plans  separately  and  in  order. 

Laparotomy.  In  recent  years  surgeons  have  advocated  this 
method  of  treating  intussusception  as  being  comparatively  safe, 
and  more  certain  than  other  means  of  treatment. 

Modern  surgeons,  unlike  our  surgical  forefathers,  do  not  re- 
gard the  abdominal  cavity  as  the  ancient  Hebrew  did  the  "  Holy 
of  Holies,"  a  place  never  to  be  entered  except  under  certain  rare 
conditions.  On  the  contrary,  they  talk  of  making  explorative 
openings  into  the  belly,  for  the  purpose  of  diagnosis,  as  calmly 
as  if  there  was  no  danger  in  such  a  procedure. 

It  is  hardly  to  be  wondered  at,  then,  that  opening  the  abdo- 
men to  reduce  an  invagination  should  be  looked  upon  with 
favor. 

Of  course,  most  surgeons  advise  a  trial  of  other  methods  be- 
fore proceeding  to  this  last  resort,  but  we  find  in  practice 
that  they  don't  "  waste  much  time,"  as  they  call  it,  on  insuf- 
flations and  injections.  For  instance,  Mr.  Goodlie  reported 
three  cases  of  laparotomy  for  intussusception  in  children  before 
the  London  Clinical  Society.  In  the  first  case  he  says :  "  It  was 
not  thought  wise  to  spend  much  time  in  attempts  at  inflation, 
and  accordingly  abdominal  section  was  performed  at  once." 
The  tumor  was  ileo-cecal  and  easily  reduced,  and  there  was  no 
apparent  reason  why  an  injection,  properly  administered,  might 
not  have  done  just  what  his  fingers  did,  i.  e.,  reduced  the  invagi- 
nation. In  case  II.,  reported  by  him,  the  trouble  had  lasted  but 
a  few  hours,  the  tumor  was  not  large,  and  there  was  no  contra- 
indication to  attempts  at  reduction  by  injection.  Yet  he  pro- 
ceeded at  once  to  open  the  abdomen.  The  tumor  was  very 
easily  and  quickly  reduced.  The  child  died,  however,  and  Mr. 
-Goodlie,  in  commenting  on  it,  says  that  in  a  case  no  worse  than 


24  Forest  :  Intussusception  in  Children. 

this   he  should  another  time   try  inflation  before  opening  the 
abdomen. 

In  case  III.,  the  invagination  had  lasted  some  days,  and 
laparotomy  in  this  case  may  have  been  justifiable. 

"Actions  speak  louder  than  words  "  in  such  cases,  and  show 
the  drift  of  surgical  opinion  to  be  towards  a  quick  resort  to 
aparotomy. 

Treves,  of  London,  says :  "  There  is  no  reason  why  in  the 
future,  with  a  fuller  knowledge  of  the  technical  details  essential 
to  the  operation,  with  a  surer  acquaintance  with  the  clinical 
aspects  of  obstruction,  and  with  the  exercise  of  a  sounder  judg- 
ment in  the  selection  of  cases,  the  procedure  of  laparotomy 
should  not  have  a  mortality  but  little  higher  than  that  of  the 
operation  of  strangulated  hernia." 

The  height  of  boldness  in  these  cases,  however,  is  reached  by 
Bryant,  of  Guy's  Hospital,  London.  He  advises  in  his  lectures 
that  iu  every  case  of  acute  intussusception  we  should  not  wait 
for  other  treatment,  insufflation,  injections,  etc.,  but  open  the 
abdomen  at  once  and  reduce  the  invagination,  precisely  as  in  a 
case  of  a  strangulated  hernia. 

In  regard  to  Mr.  Bryant's  position,  this  question  occurs : 
Suppose  the  abdomen  opened ;  the  invagination  is  still  to  be 
reduced.  Now,  can  traction  by  the  surgeon's  fingers  on  the 
invaginated  intestine  reduce  the  tumor,  if  it  be  reducible,  with 
less  danger  and  more  readily  than  a  forcible  injection  into  the 
colon  ? 

The  injection  is  an  elastic  pressure,  and,  as  has  been  said,  di- 
lates the  sheath  of  the  tumor  at  the  same  time  that  it  with  equal 
force  presses  the  tumor  back.  Can  the  surgeon's  fingers  act  in 
this  manner?  Does  not  their  tractile  force  act  on  the  in- 
testines in  one  or  two  lines,  and  thus  would  it  not  be  more 
liable  to  tear  the  intestine  than  an  equal  force  from  a  liquid 
injected  into  the  colon  ? 

Professor  J.  B.  S.  Jackson,  of  Harvard  College  Medical 
School,  said  on  this  point  that  "  He  considers  opening  the  ab- 
dominal cavity  for  intussusception  with  a  view  to  withdrawing 
the  invagination  a  foolhardy  procedure,  since  it  (the  intestine) 
would  usually  tear  before  it  could  be  withdrawn,  even  in  com- 
paratively recent  cases." 

If,  however,  the  danger  of  lacerating  the  intestine  be  the 
same  by  either  method,  and  their  effectiveness  in  reducing  the 


Forest  :  Intussusception  in  Children.  25 

tumor  be  equal,  yet  how  infinitely  more  dangerous  is  the  treat- 
ment advocated  by  Mr.  Bryant  than  that  of  a  properly  adminis- 
tered injection. 

His  method  adds  to  the  possibility  of  lacerating  the  intestine 
the  certain  danger  of  death  from  peritonitis  or  shock  aris- 
ing from  the  abdominal  incisions  and  manipulations.  The 
latter  danger  is  not  a  slight  one  by  any  means.  The  abdominal 
cavity,  in  children  at  least,  cannot  be  opened  with  impunity. 
Treves'  tables  show  that  after  laparotomy  the  death-rate  in  chil- 
dren, even  though  the  invagination  was  "easily  reduced,"  is 
43  per  cent. 

What  is  this  high  death-rate  due  to  %  Not  to  the  reduction 
of  the  invagination,  for  that  was  "  easily  reduced." 

It  must  be  mainly  due  to  the  abdominal  section.  It  will  be 
said  that  delay  in  operating  and  consequent  exhaustion  of  the 
patient  is  the  cause  of  the  fatal  result.  It  may  be  said  in  reply 
that,  had  a  properly  given  injection  reduced  the  tumor  without 
opening  the  abdomen,  the  patient,  however  weak  and  collapsed, 
would  in  the  very  large  majority  of  these  cases  have  quickly 
rallied  and  recovered.  Numerous  cases  are  reported  where  the 
prostration  and  collapse  was  profound  and  had  continued  for 
days,  and  yet  when  the  invagination  was  reduced  without  open- 
ing the  abdomen  the  patient  quickly  recovered.  In  fact,  I  can 
find  no  case  on  record  where  the  patient  died  after  the  tumor 
was  once  reduced  by  insufflation  or  injection. 

But  we  need  to  ask  here^  if  the  reduction  of  the  invagination 
was  "  easy,"  why  was  the  operation  of  laparotomy  necessary  at 
all? 

It  would  seem,  from  the  nature  of  the  problem,  that  any  case 
of  invagination  in  the  large  intestine  that  can  be  easily  reduced 
by  the  surgeon's  fingers  might  have  been  safely  reduced  by  the 
direct  pressure  of  liquid  injected  into  the  colon. 

The  force  thus  exerted  ought  to  be  as  safe  and  effective  in 
untwisting  and  pushing  back  the  intestinal  tumor  as  the  pulling 
and  pushing  by  the  surgeon's  fingers  after  the  abdomen  i& 
opened. 

Surely,  then,  the  grave  operation  of  laparotomy  should  be 
reserved  for  cases  that  cannot  be  reduced  by  the  simple  opera- 
tion of  giving  a  forcible  injection. 

Now,  what  have  been  the  results  of  laparotomy  for  intus- 
susceoticn  in  children  where  the  invagination  "  was  reduced  with 


26  Forest:  Intu$susce2ition  in  Children. 

difficulty  or  was  irreducible  "  ?  According  to  the  statistics  of 
Leichtenstern,  of  Treves,  and  of  Schramm,  who  have  collected 
by  far  the  largest  number  of  these  cases  of  any  authors,  the 
death-rate  after  laparotomy  "  where  the  invagination  was  diffi- 
cult or  irreducible  "  was  just  100  per  cent ;  not  a  single  case 
recovered.  Laparotomy  has  succeeded  in  57  per  cent  of  the 
cases  where  it  was  not  indicated  at  all,  where  simpler,  and 
less  dangerous  methods  would  have  succeeded  far  better ;  and, 
according  to  statistics,  has  failed  in  every  case  where  laparotomy 
was  really  indicated.  These  conclusions  only  apply  to  children 
under  12  or  15  years  of  age. 

Spontaneous  Cure.  The  second  course  open  in  an  obstinate 
case  is  to  leave  it  to  nature.  What  are  the  statistics  of  opera- 
tions by  sloughing  of  the  invaginated  portion  of  the  intestine, 
and  how  do  these  compare  with  laparotomy  ? 

In  the  infant,  spontaneous  elimination  takes  place  in  only  2 
per  cent  of  the  cases,  and  even  these  do  not  recover.  In  the 
second  to  the  fifth  year  of  age,  spontaneous  elimination  takes 
place  in  only  6  per  cent  of  the  cases,  and  most  of  these  die. 
Hence,  up  to  the  sixth  year  of  age  nature  fails  to  cure  these 
cases  because  the  child's  strength  gives  out  before  the  slough 
can  be  thrown  off. 

Between  the  sixth  and  eleventh  year,  however,  spontaneous 
elimination  takes  place  in  38  per  cent  of  the  cases  ;  and  recovery 
takes  place  in  42  per  cent  of  those  that  undergo  spontaneous 
elimination.  In  other  words,  22  per  cent  of  all  cases  of  intus- 
susception that  occur  between  6  and  10  years  of  age  recover 
by  nature's  operation. 

We  may  suppose  those  cases  of  spontaneous  elimination  cases. 
"  difficult  or  impossible  to  reduce" — at  least  they  never  were 
reduced,  although  in  most  of  them  attempts  were  made  to  do 
so.  When  we  compare  nature's  results  in  these  cases  with  those 
of  laparotomy  in  "  difficult  "  cases,  we  are  struck  by  the  advan- 
tage of  nature's  method  over  that  of  the  surgeon. 

In  children  over  10  years  of  age,  nature's  operation  gives  still 
better  results. 

Hence  it  does  not  follow  that,  if  one  cannot  reduce  an  inva- 
gination in  all  cases  by  an  injection,  he  should,  of  course,  call 
in  a  surgeon  to  open  the  abdomen. 

This  depends,  among  other  things,  on  the  age  of  the  patient.. 

Forcible  Injections.     The  third  course  open  in  any  case  that 


Forest  :  Intussusception  in  Children.  27 

resists  an  injection  given  with  a  safe  degree  of  force  (six  or 
seven  pounds  pressure  to  the  square  inch)  is  to  resort  to  still 
greater  force,  say  nine  or  ten  pounds  pressure  to  the  square  inch. 
This  cannot  be  done  without  danger  of  rupturing  the  intestine, 
and  thus  causing  the  death  of  the  patient. 

But  it  must  be  borne  in  mind  that  these  cases  are  dangerous 
ones,  at  the  best,  and — whether  we  leave  them  to  nature,  or  re- 
sort to  laparotomy— the  death  rate  must  be  very  high  in  any  case. 
In  children  under  6  years  of  age,  either  laparotomy  or  nature's 
operation  is  almost  always  fatal ;  hence  we  would  be  justified 
in  running  some  risk  in  giving  a  forcible  injection  in  these  cases. 
Not  to  draw  this  out  too  far,  let  me  state  in  a  few  words  the 
course  I  would  recommend  in  all  oases  of  intussusception  in 
children. 

A  pressure  of  six  pounds  to  the  square  inch  having  failed  to 
reduce  the  tumor  after  a  lengthened  trial,  I  should  cautiously 
raise  the  pressure  to  seven  and  eight  pounds,  and  even  nine 
pounds  to  the  square  inch,  depending  on  the  acuteness  of  the 
attack  and  the  length  of  time  the  invagination  had  continued. 
This  having  failed,  what  course  should  then  be  followed  % 

If  the  child  be  under  2  years  of  age,  open  the  abdomen  at 
once  and  resect  the  intestine.  The  child  will  probably  die  ;  but, 
if  left  to  nature,  the  case  it  absolutely  hopeless. 

If  the  child  be  between  2  and  5  years  of  age,  and  injections 
have  failed,  the  chances  of  cure  by  sloughing  or  from  lapa- 
rotomy are  about  equal,  and  the  surgeon  will  be  justified  in 
following  either  course.  Remember  that  the  invagination  prob- 
ably cannot  be  reduced  even  by  traction,  and  the  principal  ob- 
ject in  opening  the  abdomen  is  to  resect  the  intestine,  or  to  per- 
form enterotomy. 

If,  however,  the  child  be  over  five  years  of  age,  and  the  tumor 
has  resisted  a  pressure  of  eight  or  nine  or  ten  pounds  to  the 
square  inch  without  being  reduced,  we  must  conclude  that  it  is 
irreducible. 

Now,  according  to  statistics  given  above,  the  operation  of 
laparotomy  in  these  cases  shows  a  greater  death  rate  than  the 
cure  by  sloughing,  the  "  spontaneous  cure  ;  "  therefore,  nature's 
operation,  nearly  hopeless  as  it  is,  should  be  preferred  to  lapa- 
rotomy. 
29  Washington  Square,  New  York. 


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